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Adults with depression

By April Ruiz,2014-01-10 19:27
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Adults with depression

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    Adults with depression

Pharmaceutical care model scheme

    Case study 1:

Laura is a 30 year old, first time mother with an eight week old baby daughter.

    She is a regular customer at your pharmacy. You advised her to speak to her

    GP two weeks ago when she asked you if it was okay to take St John’s Wort

    for low mood and tiredness. Laura comes back to the pharmacy with a

    prescription for sertraline 50mg daily and asks “Is it okay to take sertraline

    when I am breast-feeding?”

Her GP has only told her to take them and come back in 4 weeks.

What are the actual or potential care issues?

Adverse effects No drug is recommended by its manufacturer for use whilst

    breastfeeding. But, there are not thought to be problems in the short-term or

    long-term development of children breast-feed by mothers taking

    antidepressants. Sertraline has been given to breastfeeding mothers the only

    difficulty reported has been if sertraline is stopped suddenly and the baby has

    shown discontinuation symptoms which resolved after a few days. The baby`s

    progress should be monitored and they should observed for drowsiness and

    poor feeding.

If a decision is taken to continue breastfeeding, strategies my be considered

    to minimise the risk of medicines effects in the infant e.g. time the feeds to

    avoid peak levels in the milk or express milk to give later. NB. Peak drug

    levels for sertraline in breast milk have been observed 7-10 hours after the

    maternal dose.

Consider contacting your local Medicines information pharmacist for up-to-

    date advice on the use of particular drugs in breastfeeding if you are unsure.

Understanding and knowledge - patient counselling required - confirm what

    the GP has told her

What advice would you give to the patient?

    ? She may not feel better for two to four weeks.

    ? Explain how the medication works.

    ? It is important to continue on antidepressants for at least 6 months after

    symptoms have resolved. This will ensure that the episode has been

    effectively treated and also gives some protection afterwards.

    ? Stopping too soon could lead to relapse and if stopped abruptly can

    cause some unpleasant effects.

    ? She may feel a little nauseous at the beginning but this should go away

    after a few days.

    ? Although the patient information leaflets lists a lot of side-effects most

    are uncommon-if anything happens advise her to contact you or her

    doctor to discuss

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    Refer to the pharmaceutical care need assessment tool

    Agree and list the essential counselling points to discuss with people at the first presentation of their prescription.

    As people present each month over a 3-month period list the key points that you would re-emphasise over time and new points that you would focus on at each presentation.

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    Case study 2

James Brown a 62 year old retired baker who cares for his disabled wife. He

    has hypertension and is prescribed bendroflumethiazide 2.5mg and fluoxetine

    20mg capsules. You have noticed that his personal hygiene and care has not

    been as good recently. You ask him how he is getting on and he replies that

    he is feeling quite low. You confirm that he is taking fluoxetine for depression

    and he agrees to answer some more in-depth questions about his depression.

    Use the pharmaceutical care needs assessment as guidance.

    Pharmacist Can you tell me when you take your anti-depressant? James Just before I go to bed

    Pharmacist How long have been taking this medication at this dose? James Oh about seven months I think-ever since council started to

    force us to move from the house to a flat because of my wife’s

    wheelchair

    Pharmacist Do you know what to do if you miss a dose or were sick after

    taking it?

    James Oh not sure

    Pharmacist Has your medication made you feel better? James Well not really - the medication seemed to work but not

    anymore and I have not had a chance to discuss it with the

    doctor - I am always there for Mrs. Brown Pharmacist Do you think it is okay to stop your medication suddenly? James Oh not sure

    Pharmacist Are you sleeping well just now?

    James No, three or four hours a night, I am exhausted Pharmacist Do you check with a pharmacist before buying medicines

    including herbal and homeopathic medicine? James No

    Pharmacist Are you taking any medicines you have bought just now? James No

    Pharmacist What side effects, if any, do you think you are experiencing

    from your medication?

    James Could it be causing my sleeplessness? Pharmacist Do you ever forget to take your medication? James No

    Pharmacist Do you ever choose not to take your medication? James I miss a dose at the weekend if I am having a drink Pharmacist Would you like to ask any questions? James My neighbour thinks I should try St John’s Wort. What do you

    think?

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    What are the actual or potential care issues?

Effectiveness-treatment sub-optimal - he is still feeling low despite 7

    months of treatment.

    Understanding- he is not sure what to do if he misses a dose. He does not realise that he cannot stop taking his medication suddenly and he would not

    check with a pharmacist or his GP before buying medication.

Potential interaction if he takes St John’s Wort.

Non-compliance as he chooses not to take a dose at the weekend.

What advice would you give to the patient?

    Continue to take his medication and encourage him to make an appointment

    with his GP. You could offer to send a written referral to his GP to highlight the

    problem or phone the GP depending on local arrangements.

Advise him not to take St John’s Wort.

Offer advice on missing a dose, not suddenly stopping his medication and

    advise him to always check with a pharmacist or his GP before buying any

    medicines, including herbal remedies.

He may benefit from a local depression support group or a local carer support

    organisation. Offer information leaflets.

Advise him to keep active perhaps through hobbies or exercise.

It is better to take his medication every day - even if he is drinking to get full

    benefit. Explore how much he is drinking as this may be a contributory factor

    to his general well-being.

What recommendations, if any, would you make to their GP?

    Review anti-depressant choice in light of what the patient reports with a view

    to changing to a different class of anti-depressant.

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    Case study 3

    June Hamilton is a 55 year old lady with a long history of depression her PMR lists numerous antidepressants. You are working with your GP surgery

    to review people who have been taking anti-depressants for over one year

Pharmacist What medication (s) do you take for depression and what dose

    and when do you take it (them)?

    June Venlafaxine 150mg each morning and 75mg at bedtime Pharmacist How long have been taking this medication at this dose? June About two years

    Pharmacist Do you know what to do if you miss a dose or were sick after

    taking it?

    June Yes, the hospital pharmacist told me to take it as soon as I

    remember unless it is couple of hours before next dose Pharmacist Has your medication made you feel better? June Yes, I was thinking of cutting down now that I am feeling better Pharmacist Do you think it is okay to stop your medication suddenly? June Yes I have stopped other tablets before

    Pharmacist Have you spoken to your GP about stopping June No it is really my psychiatrist that takes to do with this-and I am

    not seeing him for a while.

    Pharmacist Are you sleeping well just now?

    June Yes this medication has been fabulous-

    Pharmacist Do you check with a pharmacist before buying medicines

    including herbal and homeopathic medicine? June Oh yes I know it can be dangerous

    Pharmacist Are you taking any medicines you have bought just now? June Just cod liver oil

    Pharmacist What side effects, if any, do you think you are experiencing

    from your medication?

    June A dry mouth

    Pharmacist Do you ever forget to take your medication? June No

    Pharmacist Do you ever choose not to take your medication? June No

    Pharmacist Would you like to ask any questions?

    June No I am fine thank you

What are the actual or potential care issues?

Understanding in relation to stopping her medication

Potential for adverse effects if she discontinues her venlafaxine abruptly

Potential for non-compliance if she decides to stop taking her venlafaxine

    without discussing this with her GP/psychiatrist.

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    What advice would you give to the patient?

    Not to discontinue her venlafaxine suddenly. She must discuss her desire to stop with her GP/psychiatrist.

    She could try sugar free gum for her dry mouth and ensure that she brushes her teeth and flosses regularly.

What are the common discontinuation symptoms reported when

    venlafaxine is stopped abruptly?

    Flu-like symptoms, electric-shock like sensations in the head, abdominal cramps, dizziness, vertigo, insomnia, vivid increased dreaming, agitation and irritability, crying spells, fatigue, sensory disturbance. Less commonly movement disorders, poor concentration and memory.

How should venlafaxine be discontinued?

    Venlafaxine should be gradually reduced to avoid the risk of discontinuation symptoms. For this patient it may take four months or so after long-term treatment. For treatment periods of 6-8 months it should be done over 6-8 weeks.

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    Case study 4

    Mr McColl is a 73 year-old man who has been coming to your pharmacy for

    many years. His wife died 18 months ago and his son and daughter live in

    Australia. He has coronary heart disease (CHD) and you are reviewing all

    patients with CHD just now as part of a joint initiative with your local GP. Use

    the pharmaceutical care needs assessment tool to guide you through the

    specific points relating to his anti-depressant medication.

From his PMR you note that he is on the following medication:

Atenolol 100mg mane

    Aspirin 75mg mane

    Amlodipine 5mg mane

    GTN spray one or two sprays when required

    Atorvastatin 40mg mane

    Paracetamol 500mg two when required

    Amitripyline 50mg

Pharmacist What are you taking your amitriptyline 50mg for and how do

    you take it?

    Mr McColl I was depressed after my wife died and I take it just before I

    go to bed.

    Pharmacist How long have been taking this medication at this dose?

    Mr McColl Since my wife died. I was devastated and it helped me

    sleep.

    Pharmacist Do you know what to do if you miss a dose or were sick

    after taking it?

    Mr McColl Take it right away I guess

    Pharmacist Has your medication made you feel better? Mr McColl Yes

    Pharmacist Do you think it is okay to stop your medication suddenly?

    Mr McColl No

    Pharmacist Do you check with a pharmacist before buying medicines

    including herbal and homeopathic medicine? Mr McColl Yes, I don’t ever need to buy anything I just take what is on

    my prescription

    Pharmacist What side effects, if any, do you think you are experiencing

    from your medication?

    Mr McColl Well the leaflets you put in side are so tiny I can’t read them

    but no that you ask I am a little constipated and I do feel a

    bit groggy in the morning

    Pharmacist Do you ever forget to take your medication? Mr McColl Never

    Pharmacist Do you ever choose not to take your medication?

    Mr McColl No

    Pharmacist Would you like to ask any questions? Mr McColl No thank you

    Pharmacist Okay there are a couple of thing I would like to check with

    your GP

    Mr McColl Okay

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What are the actual or potential care issues?

Potential adverse effects- tricyclic anti-depressants are cardio-toxic and

    should be used with caution in people with cardiac disease. He also reports

    felling “groggy” in the morning and this class of medication has been linked to

    falls in the elderly.

    Current dose 50mg daily is not considered to be a treatment dose for depression and may have only been of benefit by improving his sleep pattern

    due to drowsiness being a side effect of amitriptyline.

Potential that medication is no longer required-he has taken the

    medication for 18 months and reports feeling well-in view of this and the

    potential for adverse effects from this medication it would be worth

    considering a withdrawal with a view to stopping anti-depressant medication

    completely.

It may well be that from the outset this was prescribed for a normal grief

    reaction to help the person sleep rather than for clinical depression. In view of

    the potential for adverse effects and the time since the bereavement

    continued treatment requires review.

What advice would you give to the patient?

    Explore if he would consider reducing his medication for a trial period and

    encourage him to discuss this with his GP at his next appointment.

Encourage him to take high-fibre diet and drink plenty of fluid to help with

    constipation-if problems persists advise him to discuss with his GP.

What recommendations, if any, would you make to their GP?

    Consider withdrawing amitriptyline gradually with a view to stopping anti-

    depressant completely, if an anti-depressant is required in the future consider

    initiation of SSRI or mirtazapine.

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